CO-197 denial code: precertification, authorization or notification absent

Claim adjustment reason code 197 says: precertification, notification, authorization or pre-treatment absent. The payer requires approval or notice before this service, and has no record that it was obtained.

With group code CO, the patient can't be billed. The amount is the practice's to recover, or to lose.

• Nobody knew an approval was needed. Requirements differ by payer and plan, and change during the year.
• The approval was obtained but doesn't match the claim: a different procedure code, more units or visits than approved, different dates, or a different rendering provider or location.
• The approval expired before the date of service.
• The authorization number wasn't on the claim.
• The service was scheduled before the approval came back, and went ahead anyway.

Original Medicare requires prior authorization for a short list of services. Medicare Advantage and commercial plans require it far more often, especially for imaging, surgery, injections, therapy visits and behavioral health.

1. Check whether an approval exists. If it does, compare it line by line with the claim: code, units, dates, provider and location.
2. If it exists and matches, correct the claim with the authorization number, or appeal with the approval attached.
3. If it doesn't match, ask the payer to update it where its rules allow, then resubmit.
4. If none was obtained, ask about retro-authorization. Some payers allow it within a short window, often for urgent care.

• Check every scheduled service against the payer's current approval list.
• Build the request from the chart, with the diagnosis and history the payer asks for.
• Re-check approvals shortly before the visit, so an expired or mismatched approval is caught while it can be fixed.
• Carry the authorization number onto the claim, and check units and dates against it.

CO-197 is decided before the patient is seen, so it is prevented before the visit.

Claira Health's AI agents make sure approvals and referrals are in place before the patient is seen, and raise a hand before they run out. Your team sees only what needs a decision, and approves every step. On a 20-minute call, we’ll walk through it using one of your own denials.

Book a 20-minute call and bring a CO-197 you've had recently.